Birthing Positions: Pros and Cons
I think February is going to my month I talk about birth, since last year February was when I attended my first birth as a certified doula.
Prior to the early 1900’s, births in the United States happened in home, with either a midwife or as a free birth (parents deliver baby on their own). In a home scenario, the birthing woman, has more freedom in how they want to labor. They can listen to their bodies and choose the position that feels most comfortable for them. Around this time (early 1900’s), there was a movement of both physicians working more in hospital settings (versus doing home visits), and of women birthing more in the hospital setting. With obstetrics, there is the tale that King Louis XIV had his mistresses deliver on their backs so that he could see, which caused others to take on this practice as well. In the hospital, there are a lot of things they want to control in order to monitor what is happening with the baby and birthing mother. In order to monitor heart rate, contractions, blood pressure, it is easier for the hospital to have you limited to the bed. This is not to say that hospital settings do not allow you to change positions, especially during labor. However, once the pushing phase begins, a lot of OBGYNs (not all) will require you to push on your back, as it is easier for them to see what is happening, so that they can intervene at a moment’s notice when they feel it is necessary- (think fingers in vagina to spread perineum, or non-consented episiotomies, or use of forceps).
With all of this being said, you can look at birth, think about videos shared online, maybe a birth you have witnessed (ignore movie births, those tend to not be realistic). Women give birth standing up while walking into the hospital, bent over on hands and knees in a car, squatting over a toilet or in the shower, and of course, in the hospital bed, on their backs, with their knees spread apart.
That last position, (hospital bed, on their back, knees spread apart), is great for visualization, NOT great for getting a baby out of you naturally, or the physiological way. Why? Why is this position bad for physiology? The first answer that immediately comes to mind is gravity. When you are on your back, baby is not going against gravity, but your body is NOT in a position that allows gravity to help you, which means, your body is having to work harder in order to get this baby out. Working harder can raise your blood pressure, tire you out, fatigue baby, causing fluctuations in their blood pressure and heart rate, and if there is clock going where the hospital is measuring how long it is taking you to get this baby out, they may try to intervene (Pitocin, cesarean).
This position allows limits the movement of your sacrum and coccyx, which some people would argue these bones don’t move, but during delivery, they need to counter nutate a few degrees to allow space for baby’s head to pass through the canal. Laying on your back would apply a firm pressure to these joints preventing that movement and making it more difficult for baby to navigate their way out. This position also, externally rotates the hips, which effectively narrows the pelvic outlet as well, thus making it harder for baby to navigate out also.
So then what position should you birth in?
You can labor in any position that is comfortable for you. In early labor, meaning contractions are not consistent, nor close together, and baby is not yet engaged in the pelvis- you can sleep (if possible), you can sit and eat a meal, you can take a shower, or even do some nesting. As labor begins to intensify, that’s when all of the positions can come into play: slow dancing, leaning over a counter, sitting on a birthing ball, leaning over the edge of the bed or a couch while sitting on the birthing ball, sitting on the toilet, squatting, supported squatting with a chair or with your birthing partner, kneeling on the floor or bed and leaning onto the birthing ball, on hands and knees, side lying- supported with pillows/ props, walking, and any variation of these to make it work for you. Throughout labor you can cycle through these, you do not have to stick to just one, and you also don’t have to try them all. But movement during labor will help to promote the progression of labor.
Now, let’s say labor has been progressing, contractions are closer together, they’re intensifying, they happening longer, you’re in active labor… And then all of a sudden, contraction begin to get sporadic and the intensity decreases. This tells us, that baby’s head is not in the optimal position to apply equal pressure onto the cervix to promote dilation. So, then we want to look at balancing movements to help realign your baby’s head. These movements would be completed with the help of your birthing partner, doula, or labor nurse. We start with a jiggle to help relax the muscles surrounding the pelvis, perform a forward leaning inversion to help move baby out of the canal a little bit to make room for them to turn the way they need to and finish with a side lying release bilaterally.
If cervical checks are being performed (which they don’t have to be), your provider can tell you what station that baby is at. If baby is at a negative station, they are not fully engaged in the pelvis yet. Station 0 is they are fully engaged. Positive stations means, the head (or feet or butt) is coming out. So, depending on what station baby is in, can tell which positions may be more appropriate at that time. With higher stations, we’re focused on inlet opening, so knees out- squatting, half-kneeling, seated with legs open, child’s pose, etc… At station zero, we’re looking at midpelvis opening, which requires internal (IR) on one side and external rotation (ER) on the other side- again kneeling with one leg up, side lying positions are good here as well. At positive stations, we want outlet opening, which means both sides are internally rotated/ knees are pointing towards each other and the feet are further away from each other.
What was that? When the baby is making their way out of the cervix, we want knees towards each other, NOT far apart so that the provider can see into the canal! OH OK! Basically when it’s time to push baby out, you want to optimize hip internal rotation. You can do this on your back, however if you are on your back, make sure you have like a donut/ pillows/ sheets propped to help elevate your coccyx off the bed to allow for movement and then turn your knees in towards each other. Side lying and hands and knees can help you achieve this positioning as well, and studies have shown that these positions are better than birthing on your back. Squatting and standing don’t prioritize the internal rotation of the hips, however, gravity comes in to help with these positions.
At the end of the day, choosing the position you decide to push/ birth in, is up to how you are feeling. Do you fatigue quickly in squatting, even if it is supported? Are you exhausted from hours of labor, and want to be able to relax a little more in between contractions and pushing? Then side lying may be better for you. I do recommend that all pregnant women take the time to try out all of the positions, so that you can know if the position is comfortable to you, and so that you will have some muscle memory for that position- so that during labor, you can trust your body to move into whichever position will work best for you in that moment.
References:
PMID: 22994881
https://doi.org/10.1016/j.cmpb.2020.105921
PMID: 37465720
